Same as linseed!
Found in smoothies, bird seed balls, dog food, varnish, and omega 3 supplement capsules!
No cross reactivity with other seeds eg sesame!
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Bell pepper allergy
The names get confusing!
Bell peppers or sweet peppers (capsicum) come in red, yellow and green varieties. The colour just tells you how ripe it is, they are the same thing!
They are related to potato, tomato, aubergine, latex (the nightshade family). You are not automatically allergic to all of these things, but you may have a higher risk if you are already allergic to one or more of them.
Chilli peppers are closely related to bell pepper. There are lots of different ones, both red and green eg bird’s eye, Scotch bonnet, jalapeno, chipotle.
Chilli powder, paprika, cayenne, pimento are all spices made from these plants, so if you are allergic to the vegetable there’s a good chance you will react to these spices too. These get used to make pepperoni, salami, chorizo sausage and others.
Black and white pepper are completely unrelated! You do not need to avoid these.
Cross contamination can be a big problem, since in restaurants, the same knife and chopping board will get used for chopping bell peppers and all other vegetables. Chargrilled food is also a risk if cooked on the same surface as roast peppers! Ask restaurants to use separate knives, chopping boards, frying pan etc.
Ketchup, baked beans, BBQ sauce, crisp flavourings, stock cubes, soups are all potentially a problem, as are most ready meals, you will need to look closely at the ingredients label.
Paprika extract is used as red/orange colouring in lots of things.
You might need to avoid anything with unidentified ‘spices’ or ‘flavourings’ until you can get further details from the manufacturer.
You may not react if the amount of spice used is very low, but this is hard to predict and you may find that one time you don’t react but another time you do react to the very same thing.
Abroad, food can be very different and you need to be much more careful. In Serbia and Croatia, for instance, there is a traditional tomato sauce ajvar that often gets served on the side of meals, which is made with red peppers.
(With thanks to Julia Marriott)
Bloody Stools
Bloody stools, think VTEC rules!
Acute bloody diarrhoea usually infective –
- Shigella/salmonella (non typhoid strains)
- Campylobacter
- E coli (some, eg EHEC)
Usually worse abdominal pain than usually seen in gastroenteritis, can also be high fever. If severe, shigella/campylobacter can be treated with antibiotics.
If chronic, consider
- constipation (stools might be soft but would expect them then to be massive)
- cow’s milk protein allergy in babies (even breast fed only)
- rectal polyp
Some serious causes:
- VTEC/STEC eg E coli O157 (causing haemolytic uraemic syndrome)
- Intussusception
- Acute colitis (ie ulcerative colitis, whether diagnosed or not)
Safety Nets
Top tips for safety-netting
- Be specific in the advice given – ‘If xxxx happens, please ring the surgery or out of hours provider immediately.’
- Provide a likely timescale for when you believe symptoms should have resolved – ‘Your cough should clear up soon if it’s due to the chest infection. If it’s still there in two weeks, please book an emergency appointment to see me.’
- It can be helpful to book an appointment for follow up yourself. Telling a patient you’d like to book them in to review their progress in a couple of weeks is safer than just saying, ‘book an appointment if it’s not better.’
- Consider giving written information and patient leaflets to reinforce verbal advice.
- Document the specific advice, given rather than simply saying ‘advice given’.
- Check that patients are aware of how to access advice if you’re not available, such as by giving the number of the Out Of Hours provider.
- Bear in mind the need to re-assess if symptoms are not settling, or if there is no response to the treatment you have given. Be prepared to reconsider an earlier diagnosis.
[Sarah Jarvis, MDU]
Celery Spice Mugwort syndrome
An allergy syndrome, where there is cross reactivity between mugwort (a pretty nondescript weed, pollen can cause hay fever and trigger asthma) and a wide range of foods, including:
- Fruit – esp apple, melon, peach, orange, watermelon
- Tomato
- Vegetables – esp celery, carrot, green pepper, onion, parsnip
- Spices – eg mustard, paprika, pepper, coriander, basil, dill, oregano, parsley, thyme, anise, caraway, fennel, tarragon
- Chamomile
- Sunflower seeds
You are not automatically allergic to everything, just be aware that you are at higher risk of being allergic to something else on the list if you are allergic to one or more things.
Oxo stock cubes better than others?
Mustard allergy
One of the 14 ingredients that must be highlighted on EU food labels.
Probably more common in France, not much data for UK but seems rare.
One of the spices that has cross reactivity with mugwort so look for other foods causing problems, as in celery spice mugwort syndrome.
Used in lots of different cuisines across the world eg black mustard seeds in curry, not just mustard as used on hot dogs and sandwiches. Also a key ingredient in:
- mayonnaise (more usually the egg causes problems but could be either or both),
- ready meals and other prepared foods,
- Salad dressings,
- Honey and mustard sauce eg for chicken, gammon,
- Chutneys,
- Pickles eg gherkins
Sometimes mustard leaf gets used as a vegetable!
Fractional excretion
Used to work out whether biochemical abnormalities are due to renal dysfunction. There is not really a “normal range” for sodium and potassium in the urine, because it depends whether the body is trying to retain or excrete at any given time. So urinary sodium can be undetectable in dehydration, for instance.
Since creatinine is filtered passively, you can compare how much sodium/potassium is being excreted with what you would expect, by calculating:
Sodium excretion (Urinary Na/Plasma Na), divided by creatinine clearance (urinary creatinine/Plasma creatinine). Multiply by 100 to get a percentage.
Note that creatinine in plasma is usually measured in micromoles, and in urine in millimoles. Online calculator here:
https://www.thecalculator.co/health/FENa-Calculator-309.html
If sodium low, you expect the kidneys to retain, so fractional excretion should be less than 1%. For low potassium, fractional excretion should be less than 10%. The opposite is true for high values.
Even where plasma sodium normal, fractional excretion can give you a clue to kidney disease – 1-4% suggests intrinsic renal pathology, over 4% post-renal.
Renal causes of low sodium/potassium include renal tubular acidosis (various forms), Bartter’s syndrome. Non-renal causes include GI losses (eg pyloric stenosis), Pseudo-Bartter’s syndrome (eg CF).
An alternative, possibly simpler method is transtubular potassium gradient (TTKG) :
TTKG = urine potassium/(plasma osmolality/urine osmolality)/serum potassium
For this formula to be accurate urine osmolality should be higher than plasma osmolality and urine sodium should be greater than 25 mEq/L.
Individuals with hyperkalemia should have a TTKG above 10. Values below 7 are consistent with mineralcorticoid deficiency, especially if accompanied by hyponatremia and high urine sodium concentration.
Individuals with hypokalemia should have TTKG values below 2.
Pica
Can be due to mineral deficiency or toxicity. But can become habitual, in which case motives/consequences should be explored – attention? Escape? Sensory feedback?
Usually iron deficiency, but potentially calcium, zinc. Beware vitamin deficiencies esp C.
Lead exposure can come from toys sourced from outside EU.
Houses in area built before 1950? Water companies generally screen for this, houses are occasionally notified of a hazard. But lead poisoning can also be a consequence of pica.
Complications are rare but potential for bezoar formation, gastrointestinal side effects. Toxocariasis if faeces is ingested.
Management
- Ignore or avoid negative attention (eye contact, facial expression, speech)
- Other oral stimulation eg. chew wristbands
- Reward keeping hands in pockets?
- Teach edible vs. Non-edible
- Alternative communications methods
- Provide similar smells, textures, colours to play with or eat
Nightshade family
Vast group of vegetables. As with all cross reactivity, allergy is not automatic but being allergic to one or more increases the chance you will be allergic to another.
- Tomato – but see also salicylate intolerance
- Aubergine – can contain histamine like chemicals!
- Bell pepper (capsicum) – from which you get the spice paprika, often used in other things eg salami, pepperoni
- Chilli pepper
- Potato (but not sweet potato). Raw potato is sometimes the problem (contact, obviously) rather than cooked.
BCG complications
Disseminated BCG reported, implies SCID or similar major immunodeficiency.
Severe BCG reaction can also indicate underlying TB infection!
More common issues are BCG abscess, and lymphadenitis.
Abscess at injection site appears after a few weeks, can persist for months. Treatment with isoniazid has been offered but no evidence of benefit. Incision probably makes things worse!
Non-suppurative lymphadenitis (not tender, no systemic symptoms) improves over a period of few weeks. Can progress to abscess however, with eventual spontaneous discharge and sinus formation. Healing then takes several months. Drug treatment does not appear to prevent abscess formation or speed up healing.
If an axillary abscess develops, needle aspiration can prevent perforation and sinus formation. Surgical excision might be needed if matted or multiloculated.
[ Postgrad Med J 2002;78:327–329]